Use of the valveless trocar system reduces carbon dioxide absorption during laparoscopy when compared with standard trocars.

OBJECTIVES: To prospectively compare a novel type of valveless trocar that creates a curtain of pressurized carbon dioxide [CO(2)] gas (which maintains pneumoperitoneum at a lower gas flow rate) with standard trocars; to quantify the volume of CO(2) used; and to characterize CO(2) elimination during laparoscopic renal surgery. METHODS: A total of 51 patients undergoing laparoscopic renal surgery by a single surgeon were prospectively evaluated using either the valveless trocar (n = 26) or standard trocars (n = 25). Patient demographics, operative time, volume of CO(2) gas consumed, CO(2) elimination, perioperative parameters, and postoperative complications were recorded and analyzed. RESULTS: Both patient cohorts were comparable in their preoperative demographics, including body mass index, the number of patients with chronic obstructive pulmonary disease, and smoking history. Mean operative time was lower in the valveless trocar cohort (124.1 minutes) compared with the conventional trocar group (145.6 minutes), P = .047. Use of the valveless trocar was associated with a lower volume of intraoperative CO(2) consumed (120.0 ± 82.8 vs 300.6 ± 191.5; P < .001) and reduced CO(2) elimination compared with standard trocar use after the first 16 minutes of insufflation (P < .05). Minimal complications occurred, including 2 cases of subcutaneous emphysema in the valveless trocar group, and 1 case of respiratory acidosis in the conventional trocar group. CONCLUSIONS: Use of a valveless trocar significantly reduced CO(2) consumption during transperitoneal laparoscopy. The valveless trocar also demonstrated significantly reduced CO(2) elimination and absorption when compared with the standard trocar.

Laparo-endoscopic single-site radical prostatectomy: Feasibility and technique.

BACKGROUND: As laparoscopy becomes a standard approach in many urological procedures, researchers strive to make minimally invasive surgery less invasive. Our objective was to apply recent innovations in equipment and surgical approaches to develop the technique and perform laparo-endoscopic single site radical prostatectomy (LESS-RP). METHODS: The technique for LESS-RP was derived by combining existing techniques of standard laparoscopic RP and developing techniques of urological LESS. This incorporated newly available low-profile trocars, flexible instruments and a flexible-tip laparoscope. The procedure was performed through a single 3-cm transverse infra-umbilical incision. LESS-RP was completed successfully via a single operative site without auxiliary needles or trocars. Perioperative variables and postoperative outcomes were recorded and measured. RESULTS: The operative time was 424 min and the hospital stay was 10 days because of a vesicourethral leak and ileus. The anastomotic leak resolved and the urethral catheter was removed at 4 weeks after surgery. The final pathology showed negative margins and Gleason 3 + 4 pT2c prostatic adenocarcinoma. CONCLUSIONS: LESS-RP is feasible by replicating laparoscopic RP techniques and incorporating the LESS technique with the advent of flexible-tip laparoscopes and flexible instruments. After a learning curve has been overcome, this should be further tested prospectively to compare oncological and functional outcomes with laparoscopic and robotic-assisted RP.

Laparoendoscopic single-site Pfannenstiel versus standard laparoscopic donor nephrectomy.

OBJECTIVES: To compare laparoendoscopic single-site (LESS) Pfannenstiel donor nephrectomy with a contemporary series of standard laparoscopic (SL) donor nephrectomies. METHODS: The initial 6 LESS donor nephrectomies were compared with a case-matched 6 SL donor nephrectomies within the same time period (June 2008 till March 2009). Patient characteristics (sex, age, body mass index, graft volume, and vascular anatomy), perioperative data (operative time, warm ischemia time [WIT], and estimated blood loss), and postoperative information (complications, length of stay, visual analog scale [VAS], and total morphine requirements) were collected prospectively and analyzed retrospectively. RESULTS: In the LESS group, there were no conversions to SL or open. There was no significant difference between the two groups in terms of baseline characteristics (age, body mass index, allograft volume). However, SL group included more right-sided patients (three compared with one) and more venous anomalies (retrorenal veins in two patients and multiple veins in another). There was no significant difference between SL and LESS in terms of operative time (117 vs. 142 minutes), WIT (5 minutes in both groups), estimated blood loss (150 vs. 100 mL), median length of stay (2 days in both), and total morphine equivalents (42 vs. 83 mg). None of the patients received transfusions perioperatively. A patient in the SL group developed a wound infection requiring packing and antibiotics. There were no perioperative complications in the LESS group. Although VAS scores were lower in the LESS versus SL group at each of post-operative day (POD) #2 (1.5 vs. 4) and discharge (0 vs. 2), this did not reach statistical significance. CONCLUSIONS: In this small retrospective series, SL was associated with more complex renal anatomy. However, there was no difference between the two groups in terms of WIT, narcotic requirements, and VAS scores. Therefore, the advantages of LESS may only be cosmesis. To verify these results, both procedures need to be compared prospectively in a randomized fashion.

Laparoendoscopic single-site pfannenstiel donor nephrectomy.

OBJECTIVES: To describe laparoendoscopic single site (LESS) donor nephrectomy procedure through a Pfannenstiel incision. Laparoscopic donor nephrectomy has become the standard approach in harvesting kidneys from live donors. This is usually performed through 3 ports placed in a triangular manner in addition to the Pfannenstiel incision where the kidney is removed. METHODS: Through a 5 cm Pfannenstiel incision, three 5 mm ports were placed in a triangular manner. A 5 mm flexible-tip laparoscope was used to perform laparoscopic donor nephrectomy. Before ligating the renal hilum, the superior midline trocar was exchanged for a 12-mm trocar to allow for an Endo-GIA stapler. After the kidney was placed in the entrapment sac, the anterior rectus fascia between the 2 midline ports was incised and the kidney was removed. After closure of the fascial defects, the Pfannenstiel incision was closed in a subcuticular manner. RESULTS: LESS Pfannenstiel donor nephrectomy was successfully performed in 6 patients without standard laparoscopic or open conversion. No additional needlescopic instruments were used. The median age was 46 years with median body mass index of 28.3 kg/m(2). The median operative time was 142 minutes with a median warm ischemia time of 5 minutes. Median hospital stay was 2 days and the median pain score at discharge was 0. None of the patients received transfusions perioperatively and none had peri-operative complications. CONCLUSIONS: LESS Pfannenstiel donor nephrectomy offers the benefits of improved cosmesis over the standard laparoscopic donor nephrectomy. Prospective randomized trials are needed to compare the postoperative pain levels in between these 2 techniques.

Laparoscopic versus robotic pyeloplasty: man versus machine.

With all its different presentations and etiologies, ureteropelvic junction obstruction has been a topic for much research and debate. For several decades, the 'gold standard' of treatment was unequivocally an Anderson-Hynes dismembered pyeloplasty. Various surgical modifications and minimally invasive alternatives have been studied. It was not until the last two decades that laparoscopic and robotic approaches have threatened to supplant the classic open approach as the preferred surgical treatment option. While the debate between the laparoscopic and robotic approaches has been a heavily contested one, it has rarely been founded on prospective, well-matched evidence. We review the existing literature and present our perspective on the clinical, academic and economic aspects of this contest between man and machine.

Laparoscopic radical nephrectomy for renal cell carcinoma: oncological outcomes at 10 years or more.

PURPOSE: We present oncological outcomes at a followup of 10 years or greater after laparoscopic radical nephrectomy for cancer. MATERIALS AND METHODS: Between February 1994 and March 1999 a total of 73 laparoscopic radical nephrectomies were performed by 2 surgeons for pathologically confirmed renal cell carcinoma. Data were obtained from patient charts, radiographic reports, telephone followup and a check of the Social Security Death Index. RESULTS: Mean followup was 11.2 years (range 10 to 15). Each patient completed a minimum 10-year followup. Mean patient age at surgery was 60 years. Mean tumor size on computerized tomography was 5 cm (range 1.7 to 13). Pathological stage was pT1a in 41% of cases, pT1b in 30%, pT2 in 15%, pT3a in 10%, pT3b in 3% and pT4 in 1%. High grade tumors (Fuhrman 3 or greater) were present in 18 cases (28%). A positive surgical margin occurred in 1 case. Actual 10-year overall, cancer specific and recurrence-free survival rates were 65%, 92% and 86%, respectively. Overall, cancer specific and recurrence-free survival rates at 12 years were 35%, 78% and 77%, respectively. At a mean of 67 months 10 patients (14%) had metastatic disease, of whom 8 (11%) died. CONCLUSIONS: Long-term oncological outcomes after laparoscopic radical nephrectomy for renal cell carcinoma are excellent and appear comparable to those of open surgery.

A new valve-less trocar for urologic laparoscopy: initial evaluation.

INTRODUCTION: Laparoscopic trocars typically maintain pneumoperitoneum using trap door valves and silicone seals. However, valves and seals hinder passage of instruments, cause lens smudging, trap specimens and needles being removed from the abdominal cavity, and lose their seal with repeated instrument exchange. AIM: The aim of the present study was to evaluate the feasibility of a newly designed valve-less trocar. METHODS: The valve-less trocar system creates a curtain of forced gas to maintain pneumoperitoneum. A separate unit filters smoke and recirculates captured escaping gas. The valve-less trocar was trialed in consecutive laparoscopic renal procedures of a single surgeon. Perioperative parameters and outcomes were collected and analyzed. The system's safety, advantages, and disadvantages were evaluated. Insufflation gas usage, elimination, and absorption were also measured. RESULTS: Twenty-five patients underwent laparoscopic renal procedures using the valve-less trocar system. The procedures included laparoscopic partial, radical, and donor nephrectomy. The mean patient age was 58.26 years. The mean operative time was 125 minutes and the mean drop in Hb for the cohort was 2.34 g/dL (range 0.4-5.4). Two patients developed subcutaneous emphysema and of the two patients, one developed clinically insignificant pneumomediastinum postoperatively. There were no postoperative complications. The surgeon noted that the use of a valve-less trocar decreased smudging of laparoscopes, expeditiously evacuated smoke during cauterization leading to improved visualization, maintained pneumoperitoneum even while suctioning, and resulted in easy extraction of specimens and needles. It was noted that insufflation gas consumption was low and CO(2) elimination was not impaired. CONCLUSION: Use of a valve-less trocar is safe. Decreased laparoscope smudging may translate into decreased operative times and reduced gas consumption may equate to cost savings. Additionally, its use brings several advantages and convenience to the operating surgeon. However, the system should be compared with conventional trocars prospectively to demonstrate clinical and economic benefit.

Laparoendoscopic single-site surgery of the kidney with no accessory trocars: an initial experience.

BACKGROUND AND PURPOSE: As laparoscopy becomes more commonplace for urologists, ongoing attempts are under way to minimize the number and size of incisions used for access. Laparoendoscopic single-site surgery (LESS) was developed and has been increasingly attempted as an extension of classic laparoscopy. Investigators hypothesize that LESS may offer a superior cosmetic result, faster recovery, and equivalent efficacy to laparoscopic surgery. Our aim is to present our experience with renal LESS. PATIENTS AND METHODS: A prospective data collection was performed on all patients who were undergoing renal LESS at our institution. A total of 11 renal LESS procedures were performed between July and November 2008: four LESS donor nephrectomies, two LESS radical nephrectomies, three LESS partial nephrectomies, and two LESS pyeloplasties. All LESS procedures replicated laparoscopic techniques but were performed through a single operative site using a 5-mm flexible-tip laparoscope and flexible working instruments. RESULTS: Six of the patients were men. The mean operative time was 162.4 +/- 38.5 minutes. The mean estimated blood loss was 104.5 +/- 41.6 mL, with a mean length of hospitalization of 2.4 +/- 0.8 days. There were no intraoperative complications or blood transfusions. Postoperative pain requirements were tabulated and revealed a mean in-hospital analgesic requirement of 44.8 +/- 46.7 mg (range 7-158 mg) of morphine equivalents with three patients receiving intravenous ketorolac. CONCLUSION: Renal LESS is feasible as flexible laparoscopes and instruments continue to develop. In our initial experience, expert laparoscopic surgeons were able to perform these LESS procedures with equivalent efficacy without compromising perioperative measures, including operative time, blood loss, and hospital stay. Further prospective investigation through randomized studies is necessary to elucidate differences, if any, in postoperative analgesic requirements and patient satisfaction with postoperative cosmesis, and to confirm equivalent efficacy when compared with current standards.

Glassy cell carcinoma of the urethra.

Glassy cell carcinoma is a poorly differentiated form of adenosquamous carcinoma that has never been reported in the urinary tract. We present the first case of primary glassy cell carcinoma of the urethra in a 48-year-old woman. She presented with a newly developed bulky mass protruding from her urethra. A biopsy of this mass revealed sheets of large polygonal cells with a "ground-glass" cytoplasm among a heavy inflammatory infiltrate, establishing the diagnosis of glassy cell carcinoma of the urethra. Treatment of her tumor included a combined surgical and chemotherapeutic approach.

Safety and efficacy of intratesticular injection of vital dyes for lymphatic preservation during varicocelectomy.

PURPOSE: The most common complications of varicocelectomy include failure and hydrocele formation. Various surgical approaches have been used to minimize complications and guarantee durable results. The use of vital dyes to visualize and preserve testicular lymphatics intraoperatively has been proposed to reduce the incidence of hydrocele formation. We investigated the safety of intratesticular injection of various vital dyes and their efficacy in allowing visualization of lymphatics for varicocelectomy. MATERIALS AND METHODS: Using general anesthesia, 22 adolescent rats underwent bilateral transscrotal intratesticular injection of methylene blue, isosulfan blue, trypan blue or normal saline. All rats with intratesticular injection of a vital dye underwent immediate exploration of the spermatic cord to observe for visualization of lymphatic vessels. At 3 months all rats were euthanized, and orchiectomy was performed for histological examination. RESULTS: Spermatic cord lymphatic vessels were variably visualized depending on concentration and volume of the vital dye used. Histological examination of the testicles at 3 months after injection revealed areas with necrosis of seminiferous tubules, thickened tubular basement membranes, interstitial fibrosis and hyalinization, and striking intratubular dystrophic calcification. These pathological changes were present to varying degrees in all groups. CONCLUSIONS: Although spermatic cord lymphatic channels were successfully visualized to varying degrees, intratesticular injection of vital dyes (and even normal saline) produced pathological changes in all groups, despite variation of concentration, volume and type of vital dye. Intratesticular injection of vital dyes for the visualization of lymphatics during varicocelectomy should be abandoned. Paratesticular injection of vital dyes should be used with caution.